Up to 8–18% of these annual costs could be reduced through investment in primary and community-based services ( 18). A recent report suggests that even in gatekeeping systems, patients with chronic conditions who could otherwise have been managed by primary care, yet presented for emergency care, cost the National Health Service approximately Ł1.42 billion annually ( 18). Patients with chronic conditions or multiple morbidities, especially older patients, may become lost in the complex pathways of the health care system, particularly in the absence of coordinated referral ( 15- 17). As patients typically have a limited appreciation of their diagnosis and treatment options, access to secondary care through self-referral can be subject to substantial error ( 12).
Further, it is argued that secondary care is used more efficiently, as primary care providers possess more specific knowledge than patients about the care needed ( 1, 12- 14). Gatekeeping can contribute to quality control by preventing unnecessary or repeated interventions. One prominent example is the principle of gatekeeping, in which the access to secondary and tertiary levels of care is only possible through referral from PC. Recent research suggests increased benefit in PC sectors that are able to coordinate and guide patients, as opposed to those that allow self-referral by the patient ( 1- 3, 6- 11). More recently, the value of primary care (PC) as a first point of access has been emphasized, with evidence mounting on the benefit to patients and payers in systems that focus on financial, geographic, and barrier-free access ( 1- 5). There is considerable discussion on the impact of regulating access to care as well as appropriate pathways for patients through health care systems.
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